DANA COKER KINGDON, PA

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Transcription:

PERSONAL HEALTH HISTORY AGNES KINRA, MD, PA Board Certified in Internal Medicine DANA COKER KINGDON, PA 4104 West 15 th St # 101 Plano, TX 75093 Phone 972-596-0006 Fax 972-596-0904 Name (Last, First, M.I.): DOB: Marital status: Single Married Separated Divorced Widowed Other Other Physicians Seen: Email Address: Pharmacy: Phone: Address: Mail order pharmacy (if you use one): Immunizations and dates: Tetanus Pneumovax 23 Tetanus+Whooping Cough Hepatitis A Influenza Zostavax (Shingles) Hepatitis B Gardasil Prevnar 13 List any medical problems you currently have and significant illnesses in the past: Surgeries Year Reason Hospital Other hospitalizations Year Reason Hospital Have you ever had a blood transfusion?

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers Name the Drug Strength Frequency Taken Allergies to medications Name the Drug Reaction You Had HEALTH HABITS AND PERSONAL SAFETY ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL. Exercise Sedentary (No exercise) ild exercise (i.e., climb stairs, walk 3 blocks, golf) Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.) Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes) Diet How would you describe your diet? Healthy Needs improvement Confused about what to eat Are you following any weight loss or other diet? If yes, what diet: Alcohol Do you drink alcohol? If yes, what kind? How many drinks per week? Have you ever had a problem with alcohol in the past? Are you concerned about the amount you drink? Tobacco Do you use tobacco? Please check one Never smoked Current smoker ormer smoker Occasional smoker Cigarettes per day: Chew per day: Pipes per day: Cigars per day: Number of years using tobacco: Year quit: Drugs Do you currently use recreational or street drugs? Have you ever given yourself street drugs with a needle?

HEALTH HABITS AND PERSONAL SAFETY - CONTINUED HIV and Hepatitis C Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak to your provider about your risk of this illness? The risk of contracting Hepatitis C is increased in people who have a history of intravenous drug use or receiving blood transfusions before 1992. Also, a one-time screening test is recommended for all adults born between 1945 and 1965. Would you like to discuss this screening? Personal Safety Do you live alone? Do you have frequent falls? Do you have vision or hearing loss? Do you have an Advance Directive or Living Will? Would you like information on the preparation of these? Is there any concern that you or a family member may be a victim of physical or verbal abuse? FAMILY HEALTH HISTORY AGE SIGNIFICANT HEALTH PROBLEMS AGE SIGNIFICANT HEALTH PROBLEMS Father Alive Deceased Age: Children Mother Alive Deceased Age: Grandmother Maternal Siblings Grandfather Maternal Grandmother Paternal Grandfather Paternal MEN ONLY How many times do you normally get up at night to urinate: or more Has the force of your urination decreased? Any difficulty with erection or ejaculation? Any testicular pain or swelling? For the next two items, please provide the date of the last exam, and the name of the doctor or provider Colonoscopy: PSA blood test:

WOMEN ONLY Age at onset of menstruation: Menopausal: Number of pregnancies: Number of live births: Are you having heavy or irregular periods, cramps, PMS, vaginal discharge, dryness or painful intercourse? Any menopausal symptoms that bother you? Any recent breast tenderness, lumps, or nipple discharge? For the next four items, please provide the date of the last exam, and the name of the doctor or provider PAP test or Pelvic exam: Mammogram: Bone density: Colonoscopy: MENTAL HEALTH Over the last two weeks, how often have you been bothered by the following problems? Not at all Several days More than half the days Nearly every day Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself, or that you are a failure, or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed? Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual. Thoughts that you would be better off dead or of hurting yourself in some way

OTHER PROBLEMS Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain. atigue Chest pain Weight loss or gain Palpitations Headache Shortness of breath Allergy symptoms Cough Vision changes Wheeze Dizziness Heartburn Insomnia Indigestion Daytime sleepiness Diarrhea Constipation Hemorrhoids Urinary problems Joint ache Back or neck pain Edema or swelling Vein problems Numbness Anxiety Gas/bloating Sexual problems Substance abuse concern Other concerns or added detail for the items checked above:

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